Category Archives: Suicide Assessment and Intervention

Bad News in Threes: Kate Spade, Anthony Bourdain, and the CDC Suicide Report

Rainbow 2017

My mother always said, “Bad news comes in threes.” That concept, along with many of her other superstitions, never made much sense to me.

In truth, the bad news never stops. She knew that. I suppose that organizing bad news into groups of three offered hope that the suffering might soon end—at least until the next set of three bad things came round.

This week we’ve had bad news in waves, with three particular pieces distinctly linked to suicide. On Tuesday, there was fashion designer, Kate Spade. Yesterday, there was the release of a new CDC report on Suicide. And then this morning there was Anthony Bourdain.

When people like Kate Spade and Anthony Bourdain die by suicide, it’s hard not to be mystified. By all measures, both Spade and Bourdain were highly successful. They were passionate and fully alive. The dynamics that may have led them to choose death are opaque. We can’t see these dynamics. They’re not obvious.

Another thing that’s not easily seen or especially obvious is the fact that, along with Spade and Bourdain, 865 other Americans will die by suicide this week. Let that number sink in. Many of these other American suicides will be military veterans. These 865 Americans may choose suicide for reasons similar or different than Spade and Bourdain. We can’t know the deeply personal reasons why individuals choose suicide.

In honor of my mother’s desire to manage bad news in groups of three, I’ve got some other threes to share:

Three Things to Remember About Suicide

  1. As Spade and Bourdain’s deaths illustrate, suicide is unpredictable. Many respected suicidologists have thrown suicide risk factors and warning signs into the trash bin. Because we may not know if someone is suicidal, our best strategy is to treat everyone with kindness, compassion, and respect. This approach is all about connecting with others in ways that are meaningful and authentic. Then, from the context of your interpersonal connection, if you suspect or intuit that suicide is possible, ask directly in a way that normalizes suicidal thinking. You might ask something like, “It’s not unusual for people to think about suicide. Has that been true for you?”
  2. As the CDC report highlights, a person’s mental health may or may not be linked to suicide. In the CDC’s analysis, about 54% of suicides were not associated with a known mental disorder or pre-suicide warning signs. This implies that thinking about suicide or acting on suicidal impulses may be something that arises from challenging life stresses or circumstances. This information also means that you shouldn’t blame yourself for suicide deaths. We imagine suicide to be a terrible tragedy for the person who dies, but it’s also a palpable tragedy for many survivors. Of course, if you knew a person who died by suicide you deeply wish you could have known the right thing to say or do to save that person’s life. But the reality is, suicide is unpredictable, and so you and I shouldn’t beat ourselves up over not being able to effectively intervene. If you feel guilty after a suicide, talk about your feelings with someone you trust. Although it’s natural to blame yourself, there’s no point in being alone with your guilt, so please reach out for support for yourself.
  3. The deaths of Spade and Bourdain bring suicide to the front and center of our national consciousness. Although it’s good to shine a light on suicide, the deaths of Spade and Bourdain overshadow the 865 other Americans who have or will die by suicide this week. Many of these Americans will not have sought help. The irony of not seeking help is that there are several excellent talk-therapies that specifically target suicide risk. These therapies can be highly effective. Hotlines are a fine first step and medications might help, but the interpersonal connection that comes with evidence-based talk therapies, is profoundly important to positive outcomes. Effective help is available. Let’s bring the evidence-based talk therapies front and center in our national consciousness also.

Three Evidence-Based Therapies

Here are links to the three top evidence-based therapies for suicide.

Dialectical Behavior Therapy (DBT): https://www.amazon.com/DBT%C2%AE-Skills-Training-Manual-Second/dp/1462516998/ref=sr_1_1?s=books&ie=UTF8&qid=1528498109&sr=1-1&keywords=linehan+suicide

Collaborative Assessment and Management of Suicide (CAMS): https://www.amazon.com/Managing-Suicidal-Risk-Second-Collaborative/dp/146252690X/ref=sr_1_1?s=books&ie=UTF8&qid=1528498077&sr=1-1&keywords=jobes

Cognitive Therapy for Suicide: https://www.amazon.com/Cognitive-Therapy-Suicidal-Patients-Applications/dp/1433804077/ref=sr_1_4?s=books&ie=UTF8&qid=1528497986&sr=1-4&keywords=cognitive+therapy+suicide

Three More Resources

The CDC Report, although depressing, includes excellent information. You can read it here: https://www.cdc.gov/mmwr/volumes/67/wr/mm6722a1.htm?s_cid=mm6722a1_w  You can also listen to or read an NPR interview with the report’s lead author, Deborah Stone, here: https://www.npr.org/sections/health-shots/2018/06/07/617897261/cdc-u-s-suicide-rates-have-climbed-dramatically

A while back I wrote an Op-Ed piece for the Missoulian newspaper. This Op-Ed emphasized core factors or dimensions that often drive suicidal behavior. Reading the article can give you a better understanding of suicide dynamics and could help you help others, but in no way will it make you capable of successfully preventing suicide amongst all of your family and friends. This article is available through the Missoulian: https://missoulian.com/news/opinion/columnists/suicide-prevention-ignore-the-math/article_ce3c7f1e-ab86-587e-9505-310cc00b3355.html

In January I had a suicide assessment and intervention article published in the Journal of Health Service Psychology. This article is a good resource for professionals who work with suicidal clients. It’s an easy read and might also be of interest to non-professionals seeking to understand more about how professionals work with suicidal people. https://www.nationalregister.org/pub/the-national-register-report-pub/journal-of-health-service-psychology-winter-2018/conversations-about-suicide-strategies-for-detecting-and-assessing-suicide-risk/

I wish you all a weekend of connection and healing.

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Suicide Assessment: Mood Scaling with a Suicide Floor

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The following material is adapted from an article in the Journal of Health Service Psychology. You can access the whole article here: https://www.nationalregister.org/pub/the-national-register-report-pub/journal-of-health-service-psychology-winter-2018/conversations-about-suicide-strategies-for-detecting-and-assessing-suicide-risk/

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My favorite suicide assessment procedure is to ask about suicide in the context of a mood assessment (as in a mental status examination). This procedure utilizes a scaling question to explore patient mood and possible suicide ideation (Sommers-Flanagan & Shaw, 2017). As you read through these steps, think about how you might apply this procedure with a recent or current patient of yours.

  1. Is it okay if I ask some questions about your mood? (This is an invitation for collaboration; patients can say “no,” but rarely do.)
  2. I’d like you to rate your mood right now, using a zero to 10 scale. Zero is the worst mood possible. Zero would mean you’re totally depressed and so you’re just going to kill yourself. At the top, 10 is your best possible mood (you might hold your hand up high to illustrate the top of the scale). A 10 would mean you’re as happy as you could possibly be. Maybe you would be dancing or singing or doing whatever you do when you’re extremely happy. Using that zero to 10 scale, what rating would you give your mood right now? (Each end of the scale must be anchored for mutual understanding.)
  3. What’s happening now that makes you give your mood that rating? (This is what psychoanalysts call binding affect; it links the internal mood to an external situation.) At this point, you might ask questions to have your patient elaborate, in greater detail, the reason for the current mood rating.
  4. What’s the worst or lowest mood rating you’ve ever had? (This question informs you about the patient’s lowest lows.)
  5. What was happening back then to make you feel so down? (This question binds the sad affect to an external situation; it may lead to discussing previous attempts.) Again, you might take time here to explore a previous attempt, in an effort to understand the (a) dynamics that led to it, (b) the seriousness of suicide intent, and (c) what happened to help the patient live and be with you to work on suicide.
  6. For you, what would be a normal mood rating on a normal day? (You can insert this question at any point where it fits. Often, the best point is after the first mood rating because patients will immediately tell you whether they’re a little more up or a little more down than normal. The purpose is to get your patients to define their normal.)
  7. Now tell me, what’s the best mood rating you think you’ve ever had? (The process ends with a positive mood rating.)
  8. What was happening that helped you have such a high mood rating? (The positive rating is linked to an external situation.)

This procedure is a general map that can be used more or less creatively. No doubt, when you start the process with an individual patient, there will be opportunities to stray from the procedure. For example, when exploring the low end of her mood, your patient may begin sharing a traumatic experience. If so, you are at a key choice point. Should you continue with the next step in the procedure or focus in more detail on the trauma? Either option may be appropriate and will depend on one or more of the following factors:

  • Based on your best judgment, does your client want to talk about trauma in more detail? If so, you should move in that direction and come back to the procedure later.
  • Do you have time to immediately explore the trauma? If not, then you should say so and let your patient know that when you do have time, you will be interested in hearing details.
  • Do you sense that your rapport is minimal and your client is uncomfortable sharing details? If so, then the best option is to continue with the procedure, making a mental note to check back later when your client is more comfortable.

Numbers can be useful in rating patient mood, but because every patient is unique, the meaning of specific numbers will be subjectively variable. I have interviewed teenagers and young adults who emphasize their distress by saying something like, “I’m a negative three!” Despite the fact that having a negative three rating on the suicide scale indicates—in a quantitative sense—suicide certainty, these patients are typically making a point, and may or may not be an especially high suicide risk. In contrast, I have also worked with cases where adult patients burst into tears and admit to suicide ideation after giving themselves a current mood rating of 8 or 9. One patient who rated herself as “9” explained that she always thought of herself as being a 10. For her, anything outside of a perfect mood rating as terribly disturbing.

            Several of my supervisees who work with teenagers have creatively transformed the scaling method to eliminate numbers. One supervisee engaged a patient in mood scaling using musical genres. After a collaborative conversation, they established that listening to opera 24/7 was equivalent to zero and imminent suicide, while listening to heavy metal was a solid 10. When working with a middle school boy, another former student used Yoga as zero and pizza as 10. The point of these examples is that practitioners can collaborate with patients to identify a method to discuss mood. Collaborative rating systems makes the method personally meaningful to the patient; it also involves interpersonal connection, implying that the assessment method has become simultaneously therapeutic.

The mood scaling procedure offers several advantages. First, it is a process that facilitates engagement, and engagement or interpersonal connection is central part of suicide interventions. Second, when patients bind their low and high moods to concrete external situations, you gain knowledge about the themes and triggers that lift and depress your patient’s mood. Third, as illustrated in the case where a client begins talking about trauma, the mood scaling procedure can be abandoned (temporarily or permanently) in favor of more salient therapeutic opportunities. Fourth, mood scaling flows smoothly into safety planning or other suicide interventions (e.g., “When you say that being a zero always involves you being alone, it tells me that one thing we should talk about now or later is how you can reach out to others, and we should talk about who you want to reach out to, during those times when you’re feeling like a zero. It also tells me that we should talk some more about other methods you can use to move from a zero to a one.”).

One final note: The mood scaling technique is an indirect method for assessing suicidality. As such, it is not a replacement for using a normative frame and asking directly. In fact, you should be thinking about if and when you will weave asking directly into your mood scaling process. For example, if your client says “I’m a 3” you might follow that with a normative-based direct question: “It’s not unusual for people who rate themselves as a three to sometimes have thoughts about suicide. Has that been the case for you?”

An Early Peek at the Suicide Assessment and Intervention Video Project

Helicopter CroppedBack in March, 2012, I settled into a Starbucks in Vancouver, Washington to reflect on my experiences at the annual American Counseling Association conference in San Francisco. Memories of Dr. Irvin Yalom’s keynote bubbled up in my mind, so that’s what ended up in my fingers, on my screen, and in my blog.

Several days later, I got an email from a “Dr. Yalom.” Seeing the name, I immediately felt anxiety and anticipation. First thoughts, “I meant to be positive. I hope I didn’t write anything offensive?”

The email was from Dr. Victor Yalom. It was nice . . . and supportive . . . and positive . . . and a big relief.

Victor is the owner/publisher/president or grand sultan of psychotherapy.net. Psychotherapy.net is a publisher of psychotherapy training and continuing education materials, mostly videos. Over the past 6 years Victor and I have struck up a collegial friendship. He is the biggest fan and proponent of our Clinical Interviewing video series (which he sells through psychotherapy.net). After viewing the Clinical Interviewing video, he has repeatedly asked Rita and I about doing a video for psychotherapy.net. Unfortunately, the timing never worked out, until this past fall, when we agreed to collaborate on a six-hour suicide assessment and intervention training video.

As they say in the film industry, everything is in the can. We’re down to final editing and other details. We filmed in Missoula and Mill Valley. Rather than working directly with imminently suicidal clients, we got volunteers to channel previous or potential suicide-related experiences. All this is just my way of introducing this sneak peek into this upcoming video.

Of course, reading isn’t the same as watching, but the next 2,000 words can give you a glimpse of one of the cases featured on the video. The client is a young Native American man and veteran. Many cultural issues emerge during the session, along with suicide ideation. Here’s the clip, along with my side “commentary” in bold:

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John:            Cory, I know a little bit about you, but not very much. And so maybe the best place to start is for you to tell me some things about yourself, some things about how you’ve been feeling in your life, some things about the situations that you’ve been in, and maybe help me get a sense of how I might be of help.

Cory:            Yeah, I come from a small reservation in Eastern Montana, and I was kind of – it was a comfortable life growing up. I didn’t know anything different. And I remember sitting there with my family watching the war and kind of spurred us to want to help bring honor to our tribe. So, I signed up at 17.

John:            Yeah, what tribe?

Cory:            I’m from the Lakota Sioux tribe from the Fort Peck Indian Reservation.

John:            Okay. Great, thank you. Sorry.

Cory:            So, I left at 17, and it was kind of a big deal. We had a big honor, big gathering for me, big sendoff, and it was pretty great and feeling pretty good. Deployed when I was 18 years old over to Iraq. It was going great. I felt like I was doing something. I didn’t get to talk to my family much, maybe every three months. And I didn’t know what was going on at home. Had a fiancée when I left. Life was great. Eventually time to come home and came home. And my family’s kind of in disarray. My grandma died. I didn’t get to go to her funeral. They didn’t tell me.

John:            Yeah.

Cory:            So, kind of tore me up. My fiancée left me for one of my best friends, so that was the shock of my life.

John:            Yeah. So, at least at this point I’m hearing that you were on kind of a high and feeling good at 17, get a big sendoff from your tribe, from your family, and you go, and you go to Iraq. And you get back, and things are a mess.

Cory:            Yeah. Meth kind of hit our reservation pretty hard. And family members on meth and prison and kind of whole world changed, I guess. Eventually, I didn’t – just came back and started drinking. Not sure who I was anymore. So, that was difficult, didn’t have very many people to turn to anymore. Never had a father growing up. My mom was always raising us with a couple jobs. And eventually her and her boyfriend got into drugs, so that’s kind of pretty difficult. And I didn’t know what to do anymore. And I was kind of feeling down and just kept drinking, and I kind of don’t know what to do anymore. For us it’s a honor to serve and kind of makes us who we are.

John:            Yeah.

Cory:            We view it as becoming a warrior man.

John:            Yeah.

Cory:            And I felt like I did that, and I’d bring honor back to my culture, my tribe. Yeah, just I came home. Everything’s in disarray, and I thought I was pretty stable. Eventually – and one thing, on the reservation we don’t – or culturally we don’t talk about our feelings or emotions. So, every time we do, feel pretty shame. A lot of shame comes from it. So, it’s kind of you just deal with it.

John:            Yeah, yeah. Yeah, so a couple of cultural pieces. One is that sense of honor of serving, and you hooked onto that and were living that. And then another cultural thing is, it’s a little shameful to express emotions, sadness, that kind of emotion or others.

Cory:            Yeah, I mean, I guess I could just describe it as shame. Like I feel guilty talking about it because we’re supposed to be men.

John:            You’re warriors. You’re strong.

Cory:            Yeah.

John:            And so you keep it all –

Cory:            Yeah, it’s part of who we are, death, fighting, honor, celebrating together, just part of who we are.

John:            Yeah, yeah. And then as you get back, and you’re in this disarray, and the meth on your reservation is prevalent, and you start drinking, and it sounds like that could be connected with the emotional warrior. Is that one of the ways that you might cope?

Cory:            I guess I just – kind of just helped me feel nothing.

COMMENTARY: Cory has covered lots of ground quickly. He has articulated his collectivist identity. Knowing about his collectivist identity early in the session is a very good thing. He has also mentioned multiple stressors and losses; these stressors and losses are traditional risk factors and load onto the various risk dimensions. These include: coming back from war, being a veteran, loss and betrayal by his girlfriend, his grandmother’s death, the disarray of his tribal community from meth, and other issues. In addition, one immediate challenge that’s coming into my mind is how to address alcohol, because it’s a suicide desensitizer, but it’s also helping him “feel nothing” which is consistent with his cultural value of not expressing his feelings. At this point I’m choosing to build a relationship with Cory before jumping in and discussing alcohol directly.

John:            Okay.

Cory:            Just kind of, I guess, how I dealt with it because I couldn’t talk about stuff that happened over there, and I didn’t have no male role models in my life to kind of talk about culturally with or anything.

John:            Yeah. So, I’m aware of the fact that you’ve told me, and I really appreciate it, some cultural things about you, about being a Lakota Sioux, about the reservation that you grew up on and some of the things you experienced, about the honor, about the shame, about the warrior mentality. And I’m going to do my best to track all those things. Occasionally if you think I’m just not getting it from your cultural perspective, I would love it if you would tell me, but I don’t want to put all that responsibility on you. So, I will probably every once in a while just check in to see, am I getting this right? Is that okay with you if we –

Cory:            Yeah, that’s fine.

John:            Yeah, because I just don’t want to misunderstand things because of my lack of the same cultural experience as yours. And so as I’m imagining it, you’re back. You’re drinking. It’s part of being numb.

Cory:            Uh-huh.

John:            And getting rid of those emotions. And as you talk, one question that comes to mind to me, and my guess is that this would be a dishonorable thought to have, although not an abnormal thought because it’s not unusual when people come back and life is disappointing and hard, and you’re drinking, and you’re managing those emotions, it’s just not unusual to have a thought about suicide or about killing yourself. And my guess is that would be in opposition to your culture, too, but I don’t know.

Cory:            Yes and no. One way we look at is from we’ve had everything taken from us. That’s one thing you can’t take from us. Our life is ours to give to the Creator, to Wakan Tanka which is our God. So, when it’s our time, it’s kind of our choice.

John:            Okay.

Cory:            The sad thing about it is, I’m feeling down, and a lot of times like as I grew up I had – I was probably nine years old. My first friend committed suicide. And it brings the community together. We have big honoring, big feast for his family, for him, and just days of celebrating. It’s kind of like bring the family back together. I had another friend do it after that because he was – couldn’t graduate high school and didn’t have nobody there, and he wanted his family to come back together, so he committed suicide, just felt like it’s going to bring his family back together. And it did for a bit, but meth came in again, so it kind of tore it apart.

John:            Uh-huh.

John:            So, I’m hearing two suicides of people that you knew well around the time that you graduated high school?

Cory:            Oh, one was when I was 9, and a good friend was 16. And by the time I was 18, I probably lost maybe 7 friends from drinking and driving, drugs, stabbings. So, I guess to us, I mean, death is death, so it wasn’t really a big deal, kind of a celebration and we’ll see them again.

John:            Yeah. So, for each one the family celebrates, the community celebrates –

Cory:            Uh-huh.

John:            – the life. And sometimes it almost sounds like somebody might choose suicide as an effort, it sounds like, to pull the family together to get everybody closer.

Cory:            Yeah, I guess, too, they know people will care. Pretty big sense of hopelessness there. Not many people know where to turn.

John:            Yeah. Yeah, so that’s a lot of death that you saw even by the time you graduated high school. Have you had some thoughts of suicide yourself?

Cory:            Originally when I first came back, I did. I just didn’t know what to do anymore. Then I came to college, thought I was going to – wanted to do something honorable again. Again, big celebration and sent us off to college. And I get here, and things are going well at first. Then just the culture differences, like nobody understood me, didn’t know what to do. I was doing all right in classes, but I just kind of couldn’t fit in, didn’t feel like anybody understood me. I mean, they’re all pretty nice guys and gals. I could tell they were trying to, but just something I knew they didn’t.

And then now things are getting bad again. I’m trying to sleep at night. Yeah, just every time I go to sleep, I remember one time in Iraq we were sitting there, and they decided – well, I guess Al-Qaeda, they blew a whole street, whole city block, and it just – I mean, every building came down. And we were there trying to help, and you had kids with missing arms and missing eyes and moms with no legs and crying, screaming. We were trying help as best we can, and same time people shooting at us and just didn’t know what to do.

My friend’s crying. Like why the fuck are we here? Like what are we doing here? Like this isn’t what we – not what we’re here for. Yeah, I just remember a mom with no leg carrying her helpless child just in her arms, and the child was dead. I mean, just every time I go to sleep, I just remember that kid helpless laying there. And so I’m not sleeping much, a lot of drinking still. I guess I don’t know what to do anymore.

COMMENTARY: It’s not unusual for suicidal clients to present with a vast array of psychological pain. That can be overwhelming to the client and to the therapist. Cory has shared several layers of unresolved grief, traumatic war memories. The number of people whom he has known who have died by suicide is immense. Additionally, because of his cultural norms of stoicism, I’m wanting to address these parts of his experience, while not activating intense emotions. my strategy has been and will be to use reflection of content, to avoid reflecting back strong emotions like sadness or anger, to keep his collectivist perspective in mind, and to take notes in a way so that he and I can take a more intellectual and problem-solving approach to working with him on his experiences.

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If you made it this far, a big congratulations. Acquiring skills to work effectively with clients who are suicidal is challenging, but dealing with the emotions that come up is probably even more difficult. The purpose of this training video (when it becomes available) is to help practitioners obtain knowledge, learn skills, and refine their awareness of the inner and interpersonal dynamics associated with suicide assessment and intervention. When I have more information on the video’s availability, I’ll let you know.

Suicide Assessment and Intervention: Workshop Learning Objectives!

Shirley Dog

This might be the last call for you to sign up for the upcoming suicide workshop in Missoula. To help you lean toward attending, I’m doing something against my own advice. Below I’m listing the extremely exciting workshop Learning Objectives. Why is that against my own advice? Because usually I think Learning Objectives are obnoxiously boring. However, because I’m so into this topic, the LOs seem fascinating to me. . . this is just more evidence that I’ve lost my perspective and judgment. Anyhow, here they are:

  1. Build Your Suicide Knowledge
  • Bust four BIG suicide myths
  • Deepen your understanding of the phenomenon of suicide (e.g., eight risk dimensions)
  • Articulate the pros, cons, and caveats of assessing suicide risk among students and clients
  • Review the SPRC Suicide Assessment and Management Competencies

2. Expand and Practice Suicide Assessment and Intervention Skills

  • Learn, develop, and practice skills for collecting accurate suicide assessment information
  • Integrate your understanding of the eight suicide risk dimensions into your suicide assessment and intervention process
  • Develop and practice skills for (a) asking directly, (b) assessing social connections, (c) assessing hopelessness, (d) dealing with irritability, (e) collaborative safety planning, (f) lethal means restriction, (g) using five different intervention techniques, and more.

3. Develop Your Self-Awareness and Refine Your Attitude Toward Suicide

  • Explore your attitudes toward and reactions to suicide and talk about suicide
  • Imagine how you would face and cope with completed suicides
  • Track, throughout the workshop, how the process of acquiring suicide knowledge and practicing suicide assessment and intervention skills, affects you psychologically and emotionally.

Check out the registration form here:

Suicide and MSE Registration Form 2018

Or, call 406-243-5252 to find out what you need to do to register for the Friday, April 6 workshop.

New Journal Article – Conversations about suicide: Strategies for detecting and assessing suicide risk

Hey Blog Readers.

For those of you who might be interested, I just published a new article on suicide assessment and interventions in the Journal of Health Service Psychology. The article title is, “Conversations about suicide: Strategies for detecting and assessing suicide risk.” The article is designed to help practitioners who work or may find themselves working with suicidal clients.

Here’s a link to the article: https://www.nationalregister.org/pub/the-national-register-report-pub/journal-of-health-service-psychology-winter-2018/conversations-about-suicide-strategies-for-detecting-and-assessing-suicide-risk/

John Semi Prof

Eight Core Conditions that Often Contribute to Suicide

Rainbow 2017Many professionals and media sources have proclaimed that suicide is a 100% preventable problem. Although I completely disagree with that message—and find it terribly offensive—I also believe that we should do what we can to prevent suicide.

Recently I was asked to write a journal article summarizing the conditions or dimensions that commonly contribute to suicide. To give you a flavor of these dimensions, below I’ve included brief descriptions of each one. However, I also want to emphasize that suicidologists and suicide researchers agree that death by suicide is nearly always unpredictable. Suicide is unpredictable despite the fact that, afterwards, many people and professionals will feel as though they should have “seen the signs” and done something more to prevent the death.

Knowing the following eight dimensions is useful when they’re used to enhance your compassion and capacity to collaborate with individual clients and persons. They’re not designed to be used as suicide risk factors or predictors.

Here are the eight dimensions.

Unbearable Psychological/Emotional Distress (Shneidman’s Psychache)

Shneidman (1985) originally identified “psychache” as the central psychological force leading to suicide. He defined psychache as negative emotions and psychological pain, referring to it as “the dark heart of suicide; no psychache, no suicide” (p. 200). In more modern patient-oriented language, psychache is aptly described as unbearable emotional distress. Unbearable distress can involve many factors, or center around one main trauma, loss, or other psychologically activating experiences; it may be accompanied by distinct cognitive, emotional, or physical symptoms.

Problem-Solving Impairment (Shneidman’s Mental Constriction)

Depression or low mood is commonly associated with problem-solving impairments. Originally, Shneidman called these impairments mental constriction, and defined them as “a pathological narrowing of the mind’s focus . . . which takes the form of seeing only two choices: either something painfully unsatisfactory or cessation” (1984, pp. 320–321). Researchers have reported support for Shneidman’s original ideas about mental constriction (Ghahramanlou-Holloway et al., 2012; Lau, Haigh, Christensen, Segal, & Taube-Schiff, 2012).

Agitation or Arousal (Shneidman’s Perturbation)

Agitation or arousal is consistently associated with death by suicide (Ribeiro, Silva, & Joiner, 2014). Shneidman (1985) originally used the term perturbation to refer to internal agitation that moves patients toward suicidal acts. When combined with high psychological distress and impaired problem-solving, agitation or arousal seems to push patients toward acting on suicide as a solution to their distress. Trauma, insomnia, drug use (including starting on a trial of serotonin-reuptake inhibitors), and many other factors can elevate agitation (Healy, 2009).

Thwarted Belongingness and Perceived Burdensomeness

Joiner (2005) developed an interpersonal theory of suicide. Part of his theory includes thwarted belongingness and perceived burdensomeness as contextual interpersonal factors linked to suicide. Thwarted belongingness involves unmet wishes for social connection. Perceived burdensomeness occurs when patients see themselves as flawed in ways that make them a burden to others.

Hopelessness

Hopelessness is a broad cognitive variable related to problem-solving impairment and linked to elevated suicide risk (Hagan, Podlogar, Chu, & Joiner, 2015; Strosahl, Chiles, & Linehan, 1992). Hopelessness is the belief that whatever distressing life conditions might be present will never improve. In many cases, patients hold a hopeless view—even when a rational justification for hope exists.

Suicide Desensitization

Joiner (2005) and Klonsky and May (2015) have described how fear of death or aversion to physical pain is a natural suicide deterrent present in most individuals. However, at least two situations or patterns can desensitize patients to suicide and reduce natural suicide deterrence. First, some patients may be predisposed to high pain tolerance. This predisposition is likely biogenetic, as in blood-injury phobias (Klonsky & May, 2015). Second, patients may acquire, through desensitization, a numbness that reduces natural fears of pain and suicide. Chronic pain, self-mutilation, and other experiences can be desensitizing.

Suicide Plan or Intent

In and of itself, suicide ideation is a poor predictor of suicide. Nevertheless, ideation is an important marker to explore with patients; exploring ideation can lead to asking directly about whether patients have a suicide plan. Suicide plans may or may not be associated with suicide intent. Some patients will keep a potential suicide plan on reserve, just in case their psychological pain grows unbearable. These patients do not intend to die by suicide, but they want the option and sometimes they have thought through the method(s) they might employ.

Lethal Means

Access to a lethal means is a situational dimension that substantially contributes to suicide risk. Firearms are far and away the most lethal suicide method. Specifically, Swanson, Bonnie, and Appelbaum (2015) reported that firearms result in an 84% case fatality rate. Although firearms can quickly become a politicized issue in the U.S., researchers have repeatedly found that access to firearms greatly magnifies suicide risk (Anestis & Houtsma, 2017).